pea and, on the other hand, were found in the ovary of a woman thirty years old. Admitting this theory, all cystic accumulations are at first composed of one little pocket lined with epithelium. Several of these little primitive cysts by fusing together eventually may form the largest cystic accumulations. These cysts are, therefore really and truly epitheliomata from a histologic point of view. But the taint of malignancy which the word epithelioma carries with it has caused it to be discarded clinically and adenoma has been suggested and almost universally accepted. Whether or not they are really originated in Pfluger's tube may be questioned. But that they are produced by the multiplication of the glandular elements of the ovary, is no longer the subject of any doubt.

Macroscopically, a cyst consists of one or more pockets containing a fluid of varying density and color. They may vary in size from that of an orange to large masses weighing upward of one hundred pounds and containing several gallons of fluid. When uncomplicated and free from adhesions with surrounding organs, the outside appearance is smooth and glistening, round or oval if the accumulation is unicystic, irregular in outline and presenting bosses, if polycystic, the walls being pearly white, or bluish, or pinkish in color, the pearly bluish white predominating. The outer surface is found on histological examination to be composed of connective tissue arranged in layers parallel to the outer surface; the inner surface being richly provided with epithelial cells, sometimes ciliated. In color the inner surface is glistening and of a bluish or pinkish hue, sometimes presenting irregular brown, slightly raised patches representing the site of old hemorrhages. The blood supply is derived from the anastomosis of the uterine and ovarian arteries and reaches the tumor through the pedicle, which is the narrowed portion of the tumor. The character of the fluid is thinner in large cysts than in smaller ones as a rule, and in color may be yellow, gray or grayish brown, the color depending on the extent of the hemorrhage which has taken place in the cyst cavity; rarely clots are found. The specific gravity varies from 1010 to 1030. The fluid itself is the product of the active secretion of the epithelial cells, together with a transudation of serum from the blood vessels, and the degeneration of the cells, some of them containing yellowish pigment, imparting to the

fluid its color. At one time a great deal of importance was attached to the finding of a paralbumin and great hopes were founded on its presence in differentiating cysts from ascites. Investigations along this line have led to the discovery by Pfannenstiel of a metalbumin, pseudo-mucin, which is produced from the protoplasm of the cells lining the cyst cavity and found only in the classical glandular ovarian tumors. Never in normal ovaries or dropsical Graafian follicles, and in ascitic fluid only in the presence of a tumor, also containing pseudo-mucin. This is important to bear in mind and, as illustrated in the case which I am about to report, might have had a most essential bearing in establishing a positive diagnosis had not other physical signs removed the doubt previously.

A history of this case brings out one or two questions of great practical interest in the clinical aspect of cystic accumulations in the abdominal cavity: 1st., The differrential diagnosis between ascites and ovarian cyst; and, 2nd., The rupture of cystic accumulations in the abdominal cavity.

The patient was transferred from one of the medical wards of the Charity Hospital to the gynecological service. Age 22; born in Missouri; began menstruating at 12; always painful; regular; one week; condition, single. Three years ago she noticed swelling of the abdomen, which gradually increased in size until last July. At that time the swelling was hard, round and about the size of an ordinary pregnancy. The tumor disappeared suddenly. For a period of three weeks after the disappearance of the tumor, the patient gave a history of depression, loss of appetite and gradual emaciation. From that time on the tumor reappeared slowly until the time of admission into the Hospital. One month before being transferred to the gynecologic service she was tapped and a large quantity of dark-brown fluid withdrawn. On examination, in the dorsal position a flattened condition of the abdomen was observed with a slight sagging at the sides and a well-defined small, round mass visible in the hypochondrium encroaching upon the right iliac region. Upon close examination a little red cicatrix was observed in the median line, midway between the symphysis and the umbilicus. Palpation revealed the masss to be hard; the abdomen gave a sense of resistance and fluctuation, when the hands

were moved from side to side. Percussion revealed absolute dullness over the mass, but dullness not so well marked over the rest of the abdomen. From the patient, however, it was learned that the large abdominal projection which existed before had been tapped and that a large quantity of dark fluid had been withdrawn. At once a multi-locular cyst was suspected, whose contents had been partly withdrawn by tapping from the large pocket, leaving a little pocket rendered very tense by accumulation of fluid and explaining the presence of the small hard mass. A bi-manual vaginal examination was then made and the uterus was found normal in size, pushed over a little to the left and a sense of fluctuation detected in the hard mass. The uterus was movable slightly. Further than that no more knowledge was obtained bi-manually and the question remained to be decided whether we were dealing with a solid tumor with ascites, a small cystic accumulation with ascites or, as at first suspected, a multi-locular cyst with a tense small pocket, and a large pocket partly emptied by tapping. Placing the patient in a sitting posture, the dullness was found to change, as it would in ascites. In fact, had not the tapping given us an opportunity of judging of the nature of the fluid, the dynamic conditions present were such as to simulate a free accumulation of fluid in the cavity, the fluid in the pocket being allowed to change its level by the flaccid condition of the cyst wall. A small cyst and a small ascitic accumulation are not so easily mistaken. Ascites more likely simulates a very voluminous cyst, filling the abdomen and consequently indefinitely outlined. The classical signs of ascites are: Flattening of the abdomen, dullness occupying the lower portion of the abdomen and limited by a line with its concavity upwards, when the patient is erect. In the lateral decubitus the dullness is in the flank and over the iliac fossae, the tympanitic note of the supernatent intestines being found on the opposite side, where it did not exist before. This displacement is very characteristic when it can be obtained, as is likewise the sensation of fluctuation when it can be obtained. But if we have, for instance, a sudden development of ascites, with the abdomen tense, hard and giving a sensation of fluctuation, its displacement by a change of posture is effected with more difficulty, and the percussion note does not give a correct indication. Again, in a case

like the one under consideration, the condition is such as to easily lead to an erroneous diagnosis. Kelly mentions a notorious ex ample of this kind. The viscid, dark character of the fluid drawn, however, weighed the balance in favor of a cyst. Had the fluid been clear, uncontaminated by previous hemorrhage, we can easily recognize the great assistance of the finding of pseudo-mucin by a chemical examination in clearing up doubt. The surgical indication was clear and a laparatomy was performed, and, as suspected a multi-locular cyst removed, the larger pocket extending almost up to the diaphragm and adherent to the anterior abdominal wall in front.

The second point of interest in the history of the patient is that of rupture. Of the causes which may bring about rupture, of large cystic pockets, traumatism plays an important part-blows, force and violent efforts and vomiting may bring it about. Again, a slow thinning of the cyst wall, following a fatty degeneration caused by thrombosis, or by a torsion of the pedicle, may cause a spontaneous rupture, which most frequently takes place in the abdominal cavity and is reabsorbed by the peritoneum, if the character of the fluid is not too irritating. Such an occurrence is beautifully illustrated in the history of this case, the sudden disappearance of the tumor, followed by a period of depression lasting two or three weeks, during which the reabsorption of the fluid took place. As graphically expressed in the words of the patient herself, "during that time her stomach was as flat as after the operation."

DISCUSSION.

DR. LEMANN said that very little could be added to Dr. Perrilliat's paper, but he wished to say a few words about the pathology and diagnosis of this class of cases. Cysts of the ovary were divided into two classes, namely, retention cysts (Graafian follicle cysts and corpus luteum cysts), and, secondly, cysts of new formation, which were true tumors. In the latter type of cysts it is impossible to make prognosis as to their tendency to malignancy. Papillomatous cysts were more malignant than cyst adenomata. Contrary to expectations, some cases of papillomatous cysts, where neighboring structures were apparently involved, were cured. Drysdale's corpuscles had been considered pathhognomic of ovarian

cyst, but they had recently been found in connection with other collections of serum. As to the pseudomucin he thought it may be of assistance in making a positive diagnosis, but he was not ready to accede that it was pathognomonic.

DR. PERRILLIAT, in closing the discussion, stated that he was of the opinion that multiple ovarian cysts were not merely caused by retention of fluid in the Graafian follicle. The Pfluger's tubes are the progenitors of the Graafin follicle in the embryonic development of the ovary. If a Pfluger tube does not reach the adult stage, it is a potential cyst, which only needs an exciting cause to begin its cellular activity.. This explains how a blow in the ovarian region can precipitate a cystic change in the ovarian tissue.

DR. LANDAUER reported

A Case of Adeno-Carcinoma of the Uterus.

Mrs. R., age 32. Has been married over 9 years. Has had 3 children; oldest 7, youngest nearly 3. No miscarriages. Family history entirely negative; father and mother living and healthy; 2 sisters and 1 brother, 1 sister dead, aged 30 (pneumonia); 1 brother dead, aged 23 (typhoid fever). Previous history: Has had diseases of childhood, pertusis, rubeola and varicella; had malarial fever five years ago. Present history: was well up to about 3 years ago, that is until after the birth of her youngest child; previous to that menses were always regular every four weeks, lasting from 2 to 5 days and profuse and not painful, though occasionally felt some pain. About 3 years ago she noticed that her menses were not as regular as they had been-they would start a few days sooner or later than she expected them to and would last sometimes a few hours only; at other times 6 to 8 days; sometimes they were very profuse and at other times scanty; sometimes used as many as 9 or 10 napkins daily. No pain, though about a year ago she began to notice that she would have some pain just after menses. Had never had leucorrhea before three months ago, and then noticed it came just after menstruating and each period since then she has had it and it persists from three to five days and once lasted for a week. Sometimes the discharge had an odor; this was easily verified on examination.